Basic Information
| Provider Information | |||||||||
| NPI: | 1467487538 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA COUNTY COMMUNITY SUPPORT PROGRAM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PAUQUETTE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 301 | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539010301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087425344 | ||||||||
| FaxNumber: | 6087424087 | ||||||||
| Practice Location | |||||||||
| Address1: | 2901 HUNTERS TRL | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539013403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087425344 | ||||||||
| FaxNumber: | 6087424087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POLZER | ||||||||
| AuthorizedOfficialFirstName: | PAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6087425344 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 1212 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 43429300 | 05 | WI | MEDICAID |